Appendix 2: Supervision Agreement

This supervision agreement is to be completed by the supervisor(s) and supervisee and is to be submitted to the Occupational Therapy Board of Australia prior to commencement of practice, where supervision is a requirement for registration.

Section 1 – Details and commitment of supervisor and supervisee

We agree to be engaged with each other in a supervisor/supervisee relationship:

Supervisor 1:

Last name:______First name:______

Position:______

Employing agency:______

Number of full-time equivalent years experience as an occupational therapist:______

Practice address:______

Phone work:______Mobile: ______

Fax:______Email: ______

Registration number:______Signature: ______Date:______

Supervisor 2 (if applicable):

Last name:______First name: ______

Position:______

Employing agency:______

Number of full-time equivalent years experience as an occupational therapist:______

Practice address:______

Phone work:______Mobile:______

Fax:______Email:______

Registration number:______Signature:______Date:______

Supervisee:

Last name:______First name:______

Employing agency:______

Specify hours to be worked each week:______

Practice address:______

Postal address:______

Phone work:______Mobile: ______

Fax:______Email:______

Registration number (if applicable): ______Signature:______Date:______

Supervision level at commencement:1234(circle relevant level)

Section 2 – Agreement of supervisor

Agreement of supervisor
I have read and agree to comply with the responsibilities of supervisors.
I understand:
  • the significance of supervision as a professional undertaking and commit to this role
  • my legal and professional responsibilities generally, and in relation to supervision, and will act accordingly (see the responsibilities of supervisors as set out in the Board’s Supervision guidelines)
  • that I must make every effort to ensure that the supervisee has read and agrees to comply with his/her responsibilities; understands legal responsibilities and constraints within which he/she must operate; and follows the Board’s Code of Conduct
  • the responsibility for determining the supervised practice plan and supervision reports must be informed by my assessment of the supervisee and I agree to undertake and document assessments as required
  • that I must only delegate tasks that are appropriate to the role of the supervisee and are within the competence of the individual
  • that re-assessment of competency and review of the supervised practice plan must occur regularly and that supervision reports on progress must be provided as stipulated by the Board
  • that the Performance Record for the Australian Competency Standards for Occupational Therapists (PRACSOT) 2010 provides a standardised assessment instrument that allows assessment of level of competence that is relevant for individuals where supervision is a requirement for registration, and is used as a reflective tool in conjunction with the Australian Minimum Competency Standards for New Graduate Occupational Therapists (ACSOT)
  • that I must take responsibility for the interventions carried out by occupational therapists working under my supervision to the extent described in the ‘Levels of supervision’ section in the Supervision guidelines
  • that I must provide clear direction to the supervisee
  • that I must provide honest and responsible reports as required by the Board, and
  • that overseas-trained occupational therapists under my supervision must be orientated to the Australian healthcare system and I will arrange for a program which addresses this requirement as part of the supervised practice plan.

I have read and understand:
  • the Occupational Therapy Board of Australia’s Supervision guidelines, and
  • the Performance Record for the Australian Competency Standards for Occupational Therapists (PRACSOT) 2010 and know that PRACSOT is to be used to assess competency of the supervisee and develop individual supervised practice plans and supervision reports on progress, unless otherwise agreed by the Board.

Note: Some statutory protection for supervisors exists according to the Health Practitioner Regulation National Law (section 237). See the Occupational Therapy Board of Australia’s Supervision guidelines.

Agreement of supervisor
I confirm that I am/ am not (please delete as appropriate) currently supervising more than three supervisees for the Occupational Therapy Board of Australia.
(Please provide details of how adequate supervision is to be provided for all supervisees if proposing to supervise more than three)
______
______
I have/have not (please delete as appropriate) previously provided supervision for occupational therapists where supervision is a requirement for registration. Please list names of previous occupational therapists you have supervised.
______
______
I do/do not (please delete as appropriate) have a potential conflict of interest, such as a personal or business relationship with the supervisee. Please detail any potential conflict of interest.
______
______

I have read, understand and agree to be bound by each of the above statements.

Signature of supervisor 1: ______Signature of supervisor 2: ______

Name of supervisor 1: ______Name of supervisor 2: ______

Name of supervisee: ______

Occupational Therapy Board of Australia

Supervision agreement template | 29August 2014 | Page 1 of 6

Section 3 – Agreement of supervisee

Agreement of supervisee
I have read and agree to comply with the responsibilities of supervisees.
I understand that I must:
  • familiarise myself with my legal and professional responsibilities relevant to my supervised practice, and relevant to general registration without conditions
  • abide by the responsibilities of supervisees as set out in the Board’s Supervision guidelines
  • inform my supervisor(s) at the outset of the supervision period of my experience, needs and circumstances/incidents relevant to the requirement that I practise under supervision
  • participate in assessments undertaken by my supervisor to assist in the determination of my capabilities, needs and progress
  • familiarise myself with safety policies and procedures relevant to my supervised practice and comply with these
  • follow directions and instruction from my supervisor and ask questions to clarify where necessary
  • advise my supervisor of any uncertainties and incidents in relation to my practice during the period of supervision
  • reflect on and respond to feedback
  • provide honest and responsible information as required by the Occupational Therapy Board of Australia
  • immediately cease practice in the event of supervision becoming unavailable and notify the Occupational Therapy Board of Australia in writing within seven days, and
  • if I am an overseas-trained occupational therapist, ensure I become familiar with the Australian healthcare system and that strategies which specifically address this requirement will be included in my supervised practice plan.

I do/do not (please delete as appropriate) have a potential conflict of interest, such as a personal or business relationship with my supervisor.
Please detail any potential conflict of interest.
______

I have read, understand and agree to be bound by each of the above statements.

Signature of supervisee: ______Name of supervisee: ______

Name of supervisor(s): ______

Who do you send it to?

All documentation should be sent to the AHPRA office in your capital city, as listed on Contact us section of the AHPRA website (

AHPRA
GPO Box 9958
In your capital city (refer below) / You may contact the Australian Health Practitioner Regulation Agency on 1300 419 495 or you can lodge an enquiry at
Sydney NSW 2001
Adelaide SA 5001 / Canberra ACT 2601
Perth WA 6001 / Melbourne VIC 3001
Hobart TAS 7001 / Brisbane QLD 4001
Darwin NT 0801

For information on the Occupational Therapy Board of Australia refer to the website:

Occupational Therapy Board of Australia

Supervision agreement template | 29August 2014 | Page 1 of 6